ARTHRITIS AND ORTHOPEDIC MEDICAL CLINIC

⃝ ROBERT G. APTEKAR, M.D. ⃝ MICHAEL D. BUTCHER, M.D. ⃝ DALJEET S. SAGOO, D.O

.

14651 So. Bascom Ave, suite 280 * Los Gatos, CA 95032 * 408-356-0444 * www.sjorthodocs.com

Welcome to AOMC! We look forward to giving you the best medical experience possible. Please complete both sides of this form. Let us know if you need any assistance with it.

PATIENT INFORMATION

Patient’s last name: First: Middle: Today’s Date:

Email Address :

Social Security no.: Date of Birth: / / Best phone to contact you? ( )

Home street address: City: State: ZIP Code: Age: q Male

q Female

Marital Status: q Single q Married q Divorced q Widowed Spouse’s Name: Phone #: ( )

How did you learn about our practice?

q Family q Friend q Yelp q Other q Google q Internet search

If family or friend, whom may we thank?

Is this person a patient in our office? q Yes q No

Recommended by another provider; If so whom may we thank?

Have you visited our website? q Yes q No

INSURANCE INFORMATION (Please provide us with your insurance cards.)

Do you have medical insurance? q Yes q No

Please indicate primary insurance: Group # Union/Local #

Subscriber’s name: Subscriber’s S.S.#.: Birth date: Group no.: Policy no.: Co- payment: / / $ Patient’s relationship to subscriber: q Self q Spouse q Child q Other

Name of employer: Work phone:

Employer address:

IN CASE OF EMERGENCY Name of local friend or relative (not living at same address): Relationship to patient: Home phone no.: Work phone no.:

( ) ( )

Email address of Emergency Contact :

Family Doctor: Office No.: The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize [Name of Practice] or insurance company to release any information required to process my claims. Parent/Guardian Signature: Date:

ROBERT G. APTEKAR, M.D. MICHAEL D. BUTCHER, M.D. DALJEET S. SAGOO, D.O.

221 East Hacienda Ave Suite A * Campbell, CA 95008 * (408) 356-0444 * www.sjorthodocs.com

Emergency Contact Person:

ARTHRITIS AND ORTHOPEDIC MEDICAL CLINIC

⃝ ROBERT G. APTEKAR, M.D. ⃝ MICHAEL D. BUTCHER, M.D. ⃝ DALJEET S. SAGOO, D.O

.

14651 So. Bascom Ave, suite 280 * Los Gatos, CA 95032 * 408-356-0444 * www.sjorthodocs.com

ADDITIONAL INSURANCE INFORMATION

Secondary Insurance Company: Group # Union/Local #

Name of secondary insurance (if applicable): Subscriber’s name: Group no.: Policy no.:

Address of Employer:

Patient’s relationship to subscriber: q Self q Spouse q Child q Other

Emergency Contact Person: Relationship Home Phone: Mobile Phone: Work Phone: Person responsible for account (if not you): Employer: Social Security # Date of birth: Home Address: Work Phone: Mobile Phone:

Is this person a patient in our office? q Yes q No

MEDICAL

Chief Complaint:

Related to: q Work q Auto Accident q Sports q Home q Other Body Part(s) _______________________ q Right q Left

If work related, Employer at time of incident? Date of injury: Employer: Phone: ( ) Fax: ( ) Address: City: State: Zip: Occupation: Supervisor: Employee Email Address:

q Work Related q Auto Accident (Please provide us with any affiliated paperwork)

Insurance Carrier: Claim/Policy Number:

Claim Address: City: State: Zip:

Claim Adjuster/Examiner: Phone: ( ) Fax: ( )

Mailing Address (if different from above)

Attorney Name: Phone: ( ) Fax: ( )

Address: City: State: Zip:

Medicare Patients: Please provide us a copy of your insurance cards

Medicare Subscriber: ID Number:

Do you have: q Part A q Part B

Name of Secondary/Supplemental: Subscriber/Policy Holder:

Are you… Retired q Disabled q

Signature of Patient, Guardian or Legal Representative Date

ROBERT G. APTEKAR, M.D.

221 East Hacienda Ave Suite A * Campbell, CA 95008 * (408) 356-0444 * www.sjorthodocs.com

MICHAEL D. BUTCHER, M.D. DALJEET S. SAGOO, D.O.

MEDICAL

Chief Complaint:

Related to: ❏ Work ❏ Auto Accident ❏ Sports ❏ Home ❏ Other Body Part(s) _________________ ❏ Right ❏ Left

If work related, Employer at time of accident? Date of injury:

Employer: Phone: ( ) Fax: ( )

Address: City: State: Zip:

Occupation: Supervisor: Employee Email Address:

❏ Work Related ❏ Auto Accident (Please provide us with any affiliated paperwork)

Insurance Carrier: Claim/Policy Number

Claim Address: City: State: Zip:

Claim Adjuster/Examiner: Phone: ( ) Fax: ( )

Mailing Address (if different from above)

Attorney Name: Phone: ( ) Fax: ( )

Address: City: State: Zip:

ARTHRITIS AND ORTHOPEDIC MEDICAL CLINIC

⃝ ROBERT G. APTEKAR, M.D. ⃝ MICHAEL D. BUTCHER, M.D. ⃝ DALJEET S. SAGOO, D.O

.

14651 So. Bascom Ave, suite 280 * Los Gatos, CA 95032 * 408-356-0444 * www.sjorthodocs.com

ADDITIONAL STATEMENT OPTIONS Not all services are covered by insurance. In the even you insurance plan determines a service to not be covered, you will be responsible for the complete charge. Our staff cannot guarantee you eligibility and coverage. Insurance rules and limits vary with insurance plans. If your plan denies a service, you will be responsible for the charge. We do not base your treatment plan on what your insurance plan covers or does not cover. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my own health. I authorize the physician to release any information including the diagnosis and records of any treatment or examination rendered to me or my child during the period of such medical care to third party payers and/or healthcare practitioners. I authorize and request my insurance company to pay directly to the physician or medical group insurance benefits otherwise payable to me. A $25 fee will be charged for all same day notice or appointment cancellations / no shows. I certify that I have read and understand this form to the best of my knowledge. I have answered every question completely and accurately. I will inform my physician of any change in my health and/or medication. Furthermore, I will not hold my physician, or any other member of his staff, responsible for any errors or omissions that I may have made in the completion of this form. I hereby assign to Arthritis & Orthopedic Medical Clinic any and all medical benefits otherwise payable to me for medical health treatment rendered by Arthritis & Orthopedic Medical Clinic described in the attached claim form. I acknowledge that I am still responsible for paying the above-referenced physician to the relevant insurer or payer does not pay the physician in full.

Signature of Patient Date

221 East Hacienda Ave Suite A * Campbell, CA 95008 * (408) 356-0444 * www.sjorthodocs.com

MICHAEL D. BUTCHER, M.D.ROBERT G. APTEKAR, M.D. DALJEET S. SAGOO, D. O.

ARTHRITISANDORTHOPEDICMEDICALCLINIC

Name:_______________________________________ DOB:______________ Today’sDate:____________________

Height:______________ Weight:____________

PRESENTILLNESS:Whatmedicalproblembringsyoutotheoffice?

__________________________________________________________________________________________________

Isthisproblemrelatedtoaninjury?_____________When?_________________WorkRelated?___________________

Whattreatmentshaveyoureceived?____________________________________________________________________

__________________________________________________________________________________________________

Listinchronologicalorderallhospitalizations,seriousillnesses,operations,severeinjuriesandfracturedbones.

Conditions/Operations Date/Year Hospital City/State Physician’sName____

1. ___________________________________________________________________________________________

2. ___________________________________________________________________________________________

3. ___________________________________________________________________________________________

yourmedicalcondition.PleaselistanyotherDoctorswhocurrently/orhavepreviouslytreatedyou.

Physician’sName/Specialty Address TelephoneNo.

1. ___________________________________________________________________________________________

2. ___________________________________________________________________________________________

AnyRecentX-Rays,MRI,CTscan?(Pleaselistbelow)__________________________________________________________________________________________________

HAVEYOUEVERBEENTREATEDWITHORTAKENANYOFTHEFOLLOWING:

□Ibuprofen □Celebrex □Naproxen □OtherNSAIDS____________________________________________

□CortisoneInjection □Steroids □Other:_________________________________________________________

Areyouallergictoanydrug?□Yes□NoIfyes,Whichones?_______________Reaction?_____________________

PASTMEDICALHISTORY:(Haveyoueverhadanyofthefollowing?Pleaselisttheyear.)

□HeartAttack___________ □Hepatitis___________ □Diabetes__________□Gallstones____________

□Cancer_____________ □Ulcers____________□HIV/Aids__________ □KidneyProblems__________

□HighBloodPressure_____________□Other:________________________________________________________

Foreachcheckabove,listtheconditionanditstreatment:__________________________________________________________________________________________________

SOCIALHISTORY:

PresentOccupation:____________________________Howlong?____________________Birthplace?______________

□Smoke?____________□Pks/Day?___________□DrinkAlcohol?___________□Drinksperday?____________

□SpecialDiet?_____________________________________________________________________________________

ARTHRITIS AND ORTHOPEDIC MEDICAL CLINIC

.

14651 S Bascom Avenue, Suite 280, Los Gatos, California 95032-2045 Tel: (408) 356-0444 Fax: (408) 358-5125

Patient Name:__________________________________ Age:__________ Date:___________________

MEDICATIONS Medication Dosage Frequency Prescribing Dr.

221 East Hacienda Ave Suite A * Campbell, CA 95008 Tel. (408) 356-0444 Fax: 408-358-5125

ARTHRITISANDORTHOPEDICMEDICALCLINIC

14651SBascomAvenue,Suite280,LosGatos,California95032-2045Tel:(408)356-0444Fax:(408)358-5125

Name:________________________________________________________Date:___________________________________Pleasereadthefollowingquestionscarefullyandmarkyouranswerbycompletelyfillinginthe

appropriatebubbles:Correct●IncorrectoReviewofSymptoms:DoyouPERSISTENTLYexperienceanyofthefollowing?Unexplainedfever>101degrees OYes ONo Unexplainedweightgain>30lbs OYes ONo Continuouslossofappetite OYes ONo Permanentlossofsmell OYes ONo Frequentnightsweats OYes ONo Unexplainedweightloss<30lbs OYes ONo Unexplainedseveredrymouth OYes ONoConstantringinginears OYes ONo Unexplainedsevereskinrash OYes ONo Raynaud’s OYes ONo Unexplainedhives OYes ONo Diabetes OYes ONo Unexplainedfrequentexcessivethirst OYes ONo Severefrequentdizziness OYes ONo Frequentpalpitations OYes ONoHighbloodpressure OYes ONoUnexplainedpersistentcough OYes ONoAsthma OYes ONo Unexplainedsevereabdominalpain OYes ONoBloodinstool OYes ONoUnexplainedseverevomiting OYes ONoUnexplainedpersistentswollenglands OYes ONoBloodinurine OYes ONoUnexplainedfrequentburningwithurination OYes ONoSeizures OYes ONoTremors OYes ONoNightlyrestlesslegsymptoms OYes ONoPanicattacks OYes ONoSuicidalthoughts OYes ONoAreyoureceivingcounseling OYes ONo

221 East Hacienda Ave Suite A * Campbell, CA 95008 Tel. (408) 356-0444 Fax: 408-358-5125

ARTHRITISANDORTHOPEDICMEDICALCLINIC

14651SBascomAvenue,Suite280,LosGatos,California95032-2045Tel:(408)356-0444Fax:(408)358-5125

Name:________________________________________________________Date:___________________________________Pleasereadthefollowingquestionscarefullyandmarkyouranswerbycompletelyfillingintheappropriatebubbles:Correct●IncorrectoSocialHistoryAreyoucurrentlyworking? OYes ONo Areyoumarried? OYes ONo Doyousmoke? OYes ONo Doyoudrinkmorethanthreealcoholicbeveragesperday? OYes ONo

FamilyHistoryIsyourMotherAlive? OYes ONo IsyourFatherAlive? OYes ONo AreyourSiblingsAlive? OYes ONoAreyourChildrenAlive? OYes ONo

PastMedicalHistory AreyouAllergictoanymedications? OYes ONo

Ifyoumarked“yes”abovepleasecompletethefollowingbycircling“yes”or“no”andmarkingtheboxthatbestdescribesyouallergicreactiontothedrug:

Aspirin Yes No Reaction: Rash□ Hives□ ShortnessofBreath□CodeineYes No Reaction: Rash□ Hives□ ShortnessofBreath□NSAIDS Yes No Reaction: Rash□ Hives□ ShortnessofBreath□Penicillin Yes No Reaction: Rash□ Hives□ ShortnessofBreath□Sulfa Yes No Reaction: Rash□ Hives□ ShortnessofBreath□Morphine Yes No Reaction: Rash□ Hives□ ShortnessofBreath□Tramadol Yes No Reaction: Rash□ Hives□ ShortnessofBreath□Wouldyoulikeustoassistyouinstoppingsmoking? □Yes □No

221 East Hacienda Ave Suite A * Campbell, CA 95008 Tel. (408) 356-0444 Fax: 408-358-5125

ARTHRITISANDORTHOPEDICMEDICALCLINIC

14651SBascomAvenue,Suite280,LosGatos,California95032-2045Tel:(408)356-0444Fax:(408)358-5125

Name:________________________________________________________Date:___________________________________Pleaseclearlymarkanypastsurgeriesthatapplybycompletelyfillingintheappropriatebubbles:

Correct●IncorrectoSurgicalHistory:Triggerfingerrelease OYes ORight OLeft

HandSurgery OYes ORight OLeft

Carpaltunnelrelease OYes ORight OLeft

ORIF,wrist OYes ORight OLeft

ShoulderArthroscopy OYes ORight OLeft

Footsurgery OYes ORight OLeft

Ganglioncystexcision OYes ORight OLeft

KneeArthroscopy OYes ORight OLeft

Totalkneearthroplasty OYes ORight OLeft

ACLrepair OYes ORight OLeft

Totalhiparthroplasty OYes ORight OLeft

221 East Hacienda Ave Suite A * Campbell, CA 95008 Tel. (408) 356-0444 Fax: 408-358-5125

ARTHRITISANDORTHOPEDICMEDICALCLINIC

March29,2017TocomplywithHealthandPortabilityregulationsofthegovernment,weneedtoaskforthefollowingdemographicinformation.ThisinformationisonlytofacilitatethetrackingofservicesfortheUSHealthcareReportingServices.Thecategoriesandchoicesarefromthegovernmentreportingregulations.Race:

1. Asian2. NativeHawaiian/OtherPacificIslander3. BlackofAfricanAmerican4. White5. Hispanic6. OtherRace7. OtherPacificIslander8. RefusetoReport

Language:1. English2. Other3. Indian(includesHindiandTamil)4. Spanish5. Russian

Ethnicity:1. HispanicorLatino/Latina2. NotHispanicofLatino/Latina3. RefusetoReport

Smoking:1. Idonotsmokenow.2. Ipreviouslysmoked.3. Ihaveneversmoked.4. Ideclinetoanswer.

Alcoholicbeverages:1. Idrinklessthanthreedrinksperday.2. Idrinkmorethanthreedrinksperday.3. Idon’tdrink.4. Ideclinetoanswer.

Hypertension/HighBloodPressure:1. Areyoubeingtreatedforhypertension?

a. Yesb. No

Weappreciateyourcooperationinthismatter.

5. Other Race6. Other Pacific Islander7. Refuse to Report

(Please provde language)

I smoke now.

ARTHRITISANDORTHOPEDICMEDICALCLINICMarch29,2017TOALLPATIENTSOFAOMCWearedelightedtoannounceanew“PatientPortal”toallowyouasapatienttoaccessourofficeontheinternet.ThisaccessisthroughyouremailandisacompletelyHIPPAcomplaint,securewebsiteallowingcommunicationtoandfromourpatientstoouroffice.Patientwillbeabletoaccessformstofilloutasnewpatient,request,changeorcancelappointmentorcommunicatewithourstaff.Therewillbeadditionalfeatureaddedovertime.Ifyouwouldliketoaccessthiswebsiteandparticipateinour“PatientPortal”,pleasesignbelow,givingusyouremail.Wewillthensetupausernameandpassword,emailingittoyouaswellasthewebaddress,soyoucangetstarted.Wehopeyoufindthisnewsystembeneficial.Asalways,pleaseletusknowwhatyouthinkofthenewsystem.Sincerely,RobertG.Aptekar,M.D. MichaelD.Butcher,M.D. DaljeetS.Sagoo,D.O.Yes,IwouldliketohaveaccesstothenewAOMCwebsitePatientPortal.Name:________________________________________________________ Email:____________________________________________Date:___________________________

Robert G. Aptekar, M.D. Michael D. Butcher, M.D. Daljeet S. Sagoo, D.O.

Arthritis & Orthopedic Medical Clinic

221 E. Hacienda Ave. Suite A Campbell, CA 95008

____________________________________________________________________________

ALCOHOL __________________________________________ ____________ Name: |Aomc Test Gender: | Date: Did you have a drink containing alcohol in the past year? ⃞ Yes

⃞ No

If ‘Yes’: How often did you have a drink containing alcohol in the past year? ⃞ Never (0 points) ⃞ Monthly or less (1 point)

⃞ Two to four times a month (2 points)

⃞ Two to three times per week (3 points)

⃞ Four or more times a week (4 points)

If ‘Yes’ : How many drinks did you have on a typical day when you were drinking in the past year? ⃞ 1 or 2 (0 points) ⃞ 3 or 4 (1 point)

⃞ 5 or 6 (2 points)

⃞ 7 to 9 (3 points)

⃞ 10 or more (4 points)

If ‘Yes’ : How often did you have six or more drinks on one occasion in the past year? ⃞ Never (0 points)

⃞ Less than monthly (1 point)

⃞ Monthly (2 points)

⃞ Weekly (3 points)

⃞ Daily or almost daily (4 points)

____________Points | 0

Interpretation ⃞ Positive ⃞ Negative Interpretation The AUDIT-C is scored on a scale of 0 - 12 (scores of 0 reflect no alcohol use).

● In men, a score of 4 or more is considered positive. ● In women, a score of 3 or more is considered positive.

_____________________________________________________________________________________________ Powered By eClinicalWorks LLC.

ARTHRITIS AND ORTHOPEDIC MEDICAL CLINIC 221 E. Hacienda Ave. Suite A

Campbell, CA 95008

ROBERT G. APTEKAR, M.D. Board Certified, Orthopedic Surgery

MICHAEL D. BUTCHER, M.D. Board Certified, Orthopedic Surgery

DALJEET S. SAGOO, D.O. Board Certified, Orthopedic Surgery

HIPAA Compliance Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. By signing this form, I understand that: ● Protected health information may be disclosed or used for treatment, payment, or healthcare operations. ● The practice reserves the right to change the privacy policy as allowed by law. ● The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions. ● The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease. ● The practice may condition receipt of treatment upon execution of this content. May we phone, email, or send a text to you to confirm appointments? YES NO May we leave a message on your answering machine at home or on your cell phone? YES NO May we discuss your medical condition with any member of your family? YES NO If YES, please name the members allowed: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ This consent was signed by: ________________________________________________________ (PRINT NAME PLEASE) Signature: ___________________________________________________ Date: _________ Witness: ____________________________________________________

AUTHORIZATION FOR USE AND DISCLOSURE OF MEDICAL INFORMATION

This authorization shows the healthcare provider(s) named below to release confidential medical information and records. Note: Information and records regarding treatment of minors, HIV,

psychiatric/mental health conditions, or alcohol/substance abuse have special rules that require specific

authorization. AUTHORIZATION I hereby authorize: _______________________________________________________________

Physician/Healthcare Facility

to release information regarding my medical history, illness or injury, consultation, prescriptions, treatment, diagnosis or prognosis, including x-rays, correspondence and/or medical records including those from my other health care providers that the above named health care provider may hold, by means of mail, fax, or other electronic methods. To:

Name

Address

City State Zip Code

The medical information/records will be used for the following purpose: _____________________ This authorization is: [ ] Unlimited (all records, excluding Substance Abuse, Mental Health, HIV Diagnosis/Treatment) [ ] Limited to the following medical information: _______________________________________

I also consent to the specific release of the following records:

Drug/Alcohol/Substance Abuse _______(initial) HIV Diagnosis/Treatment _______(initial) Psychiatric/Mental Health _______(initial) Genetic Information _______(initial) Tests for Antibodies to HIV _______(initial) DURATION This authorization shall be effective immediately and remain in effect until ________

Date

RESTRICTIONS Permissions for further or disclosure of this medical information is not granted unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by law. A photocopy of facsimile of this authorization shall be considered as effective and valid as the original. I have been advised of my right to receive a copy of this authorization. Signature of patient or legal/personal representative Relationship (if other than patient)

Patient’s Name (PRINT) Date

Patient’s Social Security Number Patient’s Date of Birth

Witness name Witness signature